“Troponin-negative chest pain”—a diagnostic evasion?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1682 (Published 09 May 2012) Cite this as: BMJ 2012;344:e1682
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Dr Ali is to be congratulated on his ‘Art of Medicine’ comment on “Troponin-negative chest pain” [1]. Intelligent patients need to know what the cause of their pain is and will always be dissatisfied on only being told what it is not. This is a common problem experienced by those with back pain [2].
Pain is frequently referred from the spine. Whilst this is usually recognised when referred from the cervical or lumbar spine, it is frequently missed when referred from the thoracic spine. An appropriate examination in Accident and Emergency should include the following when cardiac pain is not thought likely:
1. Palpation of the thoracic spine. This can be done whilst sitting when any kyphus can be detected (raising the possibility of degenerative disease, osteoporosis or less likely a crush fracture from malignant processes).
2. Spinal tenderness – again whilst the spine is in the sitting position using a closed fist
3. Rotation of the thoracic spine
4. Elicit local tenderness if the pain is localised anteriorly.
Diagnostic uncertainty is stressful for patients [3]. Making the doctor feel good by giving a diagnosis like “Troponin-negative chest pain” will often be harmful if it increases patient uncertainty.
Reference List
(1) Ali I. "Treponin-negative chest pain" - a diagnostic evasion? BMJ 2016;(5th March):365.
(2) Frank AO. Spinal problems in adults. In: Isenberg DA, ., Maddison P, Woo P, ., Glass D et al., editors. Oxford Textbook of Rheumatology. Third ed. Oxford: Oxford University Press; 2004. pp60-73.
(3) Mackie SL, Frank AO. Communication with patients before and after diagnostic tests. J Roy Soc Med 2015; 108(10):384.
Competing interests: No competing interests
I did not get the feeling that the stress of the article was on the interpretation of the troponin test, its prognostic value, diagnostic value, or the multiple contributors to its positivity or apparent negativity. Instead, I felt that the stress was on the the behavioural issue that seems to be increasingly pervasive at workplaces all over the NHS.
The market place has influenced clinics and clinicians so much so that the focus is now on processing patients, freeing up beds, facilitating quick discharges, getting the discharge summary with something on it out to primary care within a 24 hour time limit, so on and so forth. To make these happen and to meet the targets, there seems to be an excessive reliance that we clinicians (are forced to) place on rule-out tests, so that worst case scenarios can be ruled out and patients moved on to be someone else's problem. These rule-out tests could be used within hospitals to move patients from one specialist to another or from hospital to primary care. While this could be perceived as the ROWS (Rule Out Worst case Scenario) approach (1) that busy emergency care physicians tend to use to rule out the critical diagnosis so that patients can be admitted to the medical ward for further investigations, the increasing practice of similar strategies in a general medical admission unit can result in significant morbidity through introduction of an "availability bias" where trainees stop thinking beyond the most common and sinister diagnoses.
At a time where the traditional generalist is felt to be dying and the specialist approach is surging forward in hospitals, this approach seems to leave patients in limbo and confused without a diagnosis. Personally I feel that discharging a patient home with a "symptom" as a diagnosis is a sin in itself. To label something as "not something" is worse in my opinion. It merely lays bare our lack of holistic approach to the patient's problem for all to see. The fact that many of us feel no shame about it but instead are happy to justify it as a mere manifestation of our emasculation by the market does not bode well for the practice or teaching of medicine in hospitals for future generations.
The ability to accept and handle uncertainty and to manage the risk that comes with it is what sets apart the doctors from the boys. If we insist that the juniors should commit a diagnosis on every patient at the end of clerking, we should also insist that we have a workable diagnosis at the end of every patient discharge. A discharge diagnosis of "possible" or "probable" "musculoskeletal pain" is much more enlightening and satisfying and should not be avoided for the fear that it may be wrong or unacceptable to the hospital financial coder. A commitment to a diagnosis may bring with it the need to explain why we thought what we thought and why we did what we did as well as the need for a plan as to what should be done in the future if things dont pan out as hoped. When we lose interest in doing that, we should bow out gracefully and stop shaming ourselves on paper. I would dread to live in a world where healthcare is free and fast but I would have to run from pillar to post, from specialist to specialist, hearing " Not Diabetes" "Not Colitis" Not Fibrosis" till I hear "Cancer, but too late".
Reference
Croskerry, P. (2002), Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Academic Emergency Medicine, 9: 1184–1204. doi: 10.1197/aemj.9.11.1184
Competing interests: No competing interests
I enjoyed reading Dr Ali's commentary and of course, there is much truth in what he says.
Equally, the responses so far are equally valid, that there isn't always sufficient time to make a comprehensive diagnosis in hospital, troponin is a prognostic test and should always be considered in the light of patients symptoms and ECG changes. Part of being a doctor is dealing with diagnostic uncertainty and sometimes, we don't always come up with a unifying diagnosis. This is not to say the patient's pain is not real, but simply unexplainable. Often the best we can offer is to rule out serious and life-threatening disease, which is our overwhelming agenda, but not always that of the patient's. They will be reassured initially but left in pain and if the pain persists, may wonder "What is it then if not my heart?".
I would agree with Dr Ali that much symptomatology in secondary care, and possibly primary, has a psychological component but that is often more difficult to address with the patient who may be reluctant to consider such aetiology. If in doubt, revisit the history, as it is in there, where the diagnosis resides.
Competing interests: No competing interests
This brief article is well written and I agree the diagnostic label of 'troponin negative chest pain' is unhelpful. However the article repeats some common misconceptions which require correction.
Firstly, the article implies that the majority of patients attending hospital with chest pain have an acute coronary syndrome. This is absolutely not the case - in fact most patients with suspected acute coronary syndrome do not have it. (1) Often patients receive a label of acute coronary syndrome and this is later corrected by the cardiology registrar or consultant on call - although by then it may be too late to change the patient's perception that they have 'had a heart attack'.
Secondly, there appears to be a misunderstanding of the value of troponin testing. Troponin assays are positive when there has been myocardial necrosis. They do not give any information about the mechanism of myocardial necrosis - a positive troponin can indicate acute coronary syndrome, but may also occur in heart failure, prolonged arrhythmia, sepsis, pulmonary embolism and many other situations. (2)
Similarly, a negative troponin does not absolutely exclude a cardiac cause for symptoms - nor does it mean the patient is necessarily in a low risk group. (3) Patients with unstable angina, dynamic ECG changes, but negative troponin should be considered as having a similar risk of mortality and morbidity to those with a normal ECG but a positive troponin.
Troponin assays should generally be considered a prognostic, not a diagnostic test, and should be used in conjunction with the patients history and ECG - never alone.
1) Ekelund U. et al. Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. BMC Emergency Medicine 2002, 2:1 doi:10.1186/1471-227X-2-1
2) Korff S. et al. Differential diagnosis of elevated troponins. Heart 2006;92:7 987-993 doi:10.1136/hrt.2005.071282
3) Curzen N. Troponin in patients with chest pain BMJ 2004;329:1357-1358 (11 December), doi:10.1136/bmj.329.7479.1357
Competing interests: No competing interests
Certainly "troponin-negative chest pain" is not a diagnosis but it is a perfectly serviceable label that permits the patient to be returned to the primary care setting where, if the pain is recurrent, non-cardiac causes, such as gastrointestinal, musculoskeletal or psychiatric, can be evaluated by the general practitioner.
Expecting this process, which takes time and a knowledge of the patient's medical and social background, to take place in the middle of the night in the madhouse that is the modern secondary care medical assessment unit is frankly unrealistic..
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With the given evidence till date , we know that troponin elevation only takes place with a necrosed myocardium.
However thing are slightly muddy when you read about type 2 myocardial infarct and certainly ,more muddy when you go down the ladder with type 4a(PCI induced).
The concept of myocardial injury is resurfacing again and may be of value.
I think time has come that these people are assessed by specialised (cardiology) doctors and should have a working diagnosis rather than just "troponin negative chest pain".
However just to make things interesting,what about a chest pain , with positive troponin, ischemic ECG and angiographically smooth coronary arteries????
Competing interests: No competing interests
I perfectly agree with your comments.
Another type of diagnosis of the same type, in these days of so-called DRG billing, is one given to patients. They consult ED for a typical non-cardiac chest pain. A cardiac origin is ruled out. But the diagnosis is "Low risk acute coronary syndrome"... So now patients have the idea that they have a heart condition. This is done simply because this diagnosis is better reimbursed than "intercostal pain"...
MR
Competing interests: No competing interests
Re: “Troponin-negative chest pain”—a diagnostic evasion?
Dr Ali raises an important point regarding the implications of diagnosis by exclusion. Whilst the on-line version of his article begins "Having completed attachments in acute medicine and cardiology, I have seen quite a few patients presenting with chest pain"; an entirely reasonable statement, the print version begins "Most patients who present with chest pain have acute coronary syndrome"; a wholly inaccurate (and unreferenced) one. Most patients who present to general practice and emergency departments with chest pain do not have acute coronary syndrome,[1,2] and this further compounds the problem.
It is increasingly common, in acute hospital practice, to approach the patient with a strategy that I have described as ROAST; "Rule Out All Serious Things".[3] The clinician draws up a mental list of life-threatening diagnsotic possibilities, rules these out using a series of expensive investigations, and then discharges a successfully "ROASTed" patient back into the community with a description of what is not wrong with them.
This may leave the physician satisfied, but is bewildering to a patient who still has chest pain for which no clear explanation has been offered. Multiple investigations may also lead to incidental findings, further tests and inappropriate diagnostic labels. We must spend more time talking to patients, understanding their concerns and offering coherent information and explanations, rather than simply ordering a barrage of tests.
1. Allamsetty S, Seepana S, Griffith KE. 10 steps before you refer for chest pain. Br J Cardiol 2009;16:80-84.
2. Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, et al. Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association.
Circulation. 2010; 122: 1756-1776.
3. Benger J. Assessment and differential diagnoses in the patient with chest pain. Chapter in: Albarran J, Tagney J (Eds). Chest pain: advanced assessment and management skills. Oxford; Blackwell Publishing, 2007.
Competing interests: No competing interests